More MS news articles for April 1999

Taking Good Health for Granted

http://interactive.wsj.com/articles/SB922830565954355677.htm

By Theodore Dalrymple, the pen name of Anthony Daniels, a British physician and contributing editor of City Journal. At the end of the second millennium, we take medical progress for granted. More research equals more knowledge equals better health. And we assume, almost as if it were a human right, that an increase in life expectancy is part of the natural order of things.

We are not entirely wrong in our assumption, at least in relation to the future. Not only is there as yet no sign that we have reached the upper limit of human longevity--life expectancies continue to rise everywhere except Africa and Russia--but people are healthier in their old age than ever before. A combination of changes in lifestyle and improved medical care probably accounts for this. Our lives will almost certainly continue to become longer and healthier yet.

But when we project our assumption of never-ending progress back into the past, we are mistaken. It is wrong to assume that progress was so smoothly continuous that it amounted to a natural or inevitable state of affairs. On the contrary, the average life expectancy in ancient Rome was 25; in Hanoverian London, in the middle of the 18th century, it was--25.

No doubt there were times and places when things were a little better (it has been estimated, for example, that the life expectancy of the Aztecs, before the arrival of the Spanish, was 37 years). But only since the middle or end of the 18th century has there been a continuous improvement in the health of whole populations. In other words, the institutionalization of progress is of comparatively recent origin, and is historically quite exceptional.

We are apt to forget also how recently conditions prevailed that would now appall us. For example, the infant mortality rate in the London borough in which my father was born in 1909 was 124. That is to say, of 1,000 children born alive, 124 were dead before their first birthday. And London was then by quite a long way the healthiest of the large European capital cities.

Even by 1909, however, progress had been considerable. In my father's day, "only" two out of 10 children died before they were five years old; a century and a half earlier, the figure would have been more than five out of 10. Nowadays, by contrast, fewer than one in a hundred children die before their fifth birthday.

It took 200 years for the life chances of people in Europe and North America to be transformed so dramatically for the better, but it has taken a much shorter time in most of the Third World. Several Latin American countries now have longer life expectancies than England had at the time of my birth, and even in India the life expectancy far exceeds that of my father when he was born.

Curiously, though, the expansion in medical knowledge long preceded the improvement in any population's health. It was several hundred years before knowledge became power. For half of our millennium, a stultifying orthodoxy, based on the teachings of the Roman physician Galen, held sway. Even when his teachings were obviously wrong--he based his human anatomy on that of the pig--they were closely adhered to, and to question them was practically heretical.

For hundreds of years, it was considered beneath a physician's dignity actually to examine a patient, an attitude that lasted in attenuated form until well into the 19th century. A physician was expected to pontificate in learned fashion, preferably in Latin, not to draw conclusions from mere sensory evidence. Even when, eventually, medical men began to adopt a more empirical approach, it was a long time before patients actually derived any tangible benefit from it.

The decisive turning point in philosophical attitude is usually said to have occurred in 1543, when the Belgian anatomist Andreas Vesalius published his "De humani corporis fabrica" ("The Fabric of the Human Body"). For the first time, human anatomy was based upon what was seen at dissection rather than what ancient authorities described.

But Vesalius's work, epoch-making as it was, saved not a single human life. Eighty-five years later, in 1628, the English physician William Harvey published his "De motu cordis et sanguinis" ("The Motion of the Heart and Blood"), establishing the circulation of the blood. Widely regarded as the greatest book of experimental physiology ever written, it nevertheless saved no one's life, at least not directly, in the sense in which the discovery of insulin or penicillin did so.

Not until the Shropshire physician William Withering published his "Account of the Foxglove" in 1785 did an effective (though frequently toxic) cardiac drug become widely available. Withering learned about the digitalis-containing plant from a local herbalist. Curiously enough, I still occasionally encounter ordinary folk who accidentally poison themselves by drinking tea made from the foxgloves in their garden, which they take when they feel slightly under the weather.

For untold centuries doctors used drugs that were at best useless and at worst poisonous. Not without reason did Oliver Wendell Holmes remark in the 19th century that if the whole pharmacopoeia were thrown into the sea it would be the better for mankind and the worse for the fishes. In the second half of that century, the physician John Hastings advocated boa-constrictor droppings dissolved in half a gallon of water as a cure for tuberculosis.

Compounds of mercury, lead, antimony and arsenic were widely used; a British pharmacopoeia dating from 1917 suggests the following indications for the use of arsenic: acne, Addison's disease, anemia, asthma, cancer, cardiac weakness, chorea, dental caries, diabetes mellitus, dyspepsia, eczema, epilepsy, furunculosis, gout, Graves' disease, Hodgkin's disease, leukemia, lupus, malaria, malnutrition, neuralgia, osteomalacia, pellagra, pemphigus, pernicious anaernia, psoriasis, pulmonary tuberculosis, rheumatoid arthritis, rickets, scrofula, trypanosomiasis and urticaria.

The wonder, then, is that anyone escaped arsenic poisoning (D.H. Lawrence was offered the arsenic treatment for his TB as late as the 1920s). The list of indications for lead in the pharmacopoeia treatment is almost as long. We laugh at our foolish ancestors, but only very belatedly in the history of medicine has the realization dawned that a doctor's vague impression or even confident assertion that a treatment works is not proof, for he is naturally biased in favor of his own treatments.

The principle of the controlled trial of treatments is one of the most momentous discoveries of our age, which has revolutionized medicine and for the first time turned therapeutics into a genuine science. Does human contentment increase in tandem with technical progress? Alas no. We forget our own pasts all too readily, even when they are only a few years old (who now remembers the days when we had to have smallpox vaccinations to travel?).

The fact that people in the not distant past died much younger and suffered physical torments of the kind we are almost all spared nowadays does not console us in the least when we are ill, or even merely worried about becoming ill. No. we compare ourselves not with our ancestors but with our descendents, who will suffer from illness even less than we because of the continual progress made by medical science. The fact that there were once millions worse off than we are provides us with no comfort; the fact that there will certainly be millions better off is a kind of torment.

Many of my patients nowadays simply refuse to believe that any condition lies beyond the power of medical science to cure. While death is acknowledged at an intellectual level to be inevitable, in each individual case it is felt at an emotional level to be anomalous. Anything short of immortality is medical failure. Perhaps this helps explain why the medical profession seems to be respected in inverse proportion to its actual ability to cure disease. It was lionized when it could do practically nothing (it was not until 1930, according to one medical historian, that a visit to the doctor was more likely to benefit the patient than damage him).

Yet now that its powers are so formidable, it is regarded with cynicism and disrespect. For all our discontents, however, no one would wish to return to the days before antibiotics, X-rays, aseptic surgery, anesthesia and so forth. Before the medical progress of the past handful of decades, the most trivial injury or illness could--and often did--result in death. We lead more comfortable lives than any people have ever led in the history of mankind, and this is in no small part due to the triumph of medical science. The problem is, we don't really appreciate it.